The Death Debate

Six prominent philosophers took an unusual step earlier this year. Setting aside their differences on "many issues of public morality and policy," they joined in urging the U.S. Supreme Court to uphold two appeals courts’ rulings and give terminally ill patients a constitutional right to kill themselves.

"Though academic philosophers have been parties to amicus briefs before, as members of organizations or as representing an applied specialty like bioethics, I am unaware of any other occasion on which a group has intervened in Supreme Court litigation solely as general moral philosophers," observes Ronald Dworkin in the New York Review of Books (Mar. 27, 1997), in an introduction to the brief that he and five other professors filed. Joining Dworkin, of Oxford University and New York University, in "The Philosophers’ Brief" for physician-assisted suicide were Robert Nozick, John Rawls, and Thomas Scanlon, all of Harvard University, Thomas Nagel of NYU, and Judith Jarvis Thomson, of the Massachusetts Institute of Technology.

Though the Supreme Court did not take their advice, and instead, this past June, unanimously reversed the two lower courts, the philosophical debate is far from over.

Dworkin and his colleagues are firmly "pro-choice": "Just as it would be intolerable for government to dictate that doctors never be permitted to try to keep someone alive as long as possible, when that is what the patient wishes, so it is intolerable for government to dictate that doctors may never, under any circumstances, help someone to die who believes that further life means only degradation."

The six philosophers reject the usual moral distinction, as it has evolved among bioethicists in recent decades, between allowing someone to die (by, for instance, withdrawing "extraordinary" lifesustaining treatment) and killing that person (by, say, giving a lethal injection with the intention of causing death). In either case, they maintain, "the doctor acts with the same intention: to help the patient die." Their argument leaves J. Bottum, associate editor of First Things (June–July 1997), unimpressed. The authors of "The Philosophers’ Brief," he says, resolutely refuse "to engage in philosophical analysis." While they "dismiss as philosophically naive (‘based on a misunderstanding of the pertinent moral principles’) the commonsense distinction between letting die and killing, the brief uses such commonsense phrases as ‘in the patient’s best interest to die’ without any nod toward their philosophically difficult character. (How, a philosopher ought to ask, can it ever be in anyone’s best interest to cease to have interests?). . . And in a fairly straightforward begging of the question near the end of the text, the brief asserts that there exist patients ‘whose decisions for suicide plainly cannot be dismissed as irrational or foolish or premature,’ offering as a self-evident premise what was supposed to be proved as the conclusion."

Like Bottum, F. M. Kamm, a professor of philosophy at NYU and a visiting professor at the University of California, Los Angeles, is unwilling to give up the traditional distinction between killing and letting die. But, writing in Boston Review (Summer 1997), she nevertheless maintains that "assisted suicide (and euthanasia) are sometimes morally permissible." The "strongest case" for assisted suicide, she says, is "if the overriding aim is to end physical pain," though with modern techniques of pain control, the need may be rare. But the patient has a right to avoid pain.

Marcia Angell, executive editor of the New England Journal of Medicine (Jan. 2, 1997), argues "that if expert palliative care were available to everyone who needed it, there would be few requests for assisted suicide." For those who can’t be adequately helped, she believes, physician-assisted suicide should be available. The distinction between killing and letting die is "too doctorcentered," in her view. "We should ask ourselves not so much whether the doctor’s role is passive or active but whether the patient’s role is passive or active." The fact that assisted suicide is voluntary "provides an inherent safeguard against abuse," she believes. And recent reports from the Netherlands, where physician-assisted suicide and euthanasia have been given legal sanction since the early 1970s, "indicate that fears about a slippery slope there have not been borne out." Studies in 1990 and ’95 indicated that the incidence of doctor-assisted suicide there remained about the same, 0.2 percent of all deaths, while euthanasia increased from 1.7 percent to 2.4 percent. The investigators did not regard this jump as very significant.

But Herbert Hendin, of the American Foundation for Suicide Prevention, and two Dutch colleagues, writing in the Journal of the American Medical Association (June 4, 1997), maintain that Holland is already sliding down the "slippery slope." In recent decades, they write, "the Netherlands has moved... from euthanasia for terminally ill patients to euthanasia for those who are chronically ill, from euthanasia for physical illness to euthanasia for psychological distress, and from voluntary euthanasia to nonvoluntary and involuntary euthanasia."

According to the 1995 Netherlands study, in 0.7 percent of all deaths, physicians admitted they had actively ended patients’ lives without their explicit consent. In all, Hendin and his colleagues point out, the estimated number of deaths caused by physicians’ active intervention of one sort or another—euthanasia, assisted suicide, ending the life of a patient without his or her consent, and giving pain medication with the explicit intention of ending the patient’s life—increased from 4,813 (or 3.7 percent of all deaths) in 1990 to 6,368 (or 4.7 percent) five years later.

Medical standards in the care of terminally ill patients in the Netherlands have eroded, and doctors have failed to take advantage of advances in palliative care, Hendin and his coauthors argue, as euthanasia, "intended originally for the exceptional case," has become an accepted form of "treatment." In one recent case, they report, a Dutch patient with cancer who had said she did not want euthanasia "had her life ended because in the physician’s words, ‘It could have taken another week before she died. I just needed this bed.’ "